What is the biggest problem that you're having with your teeth?
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I'm missing 1-2 teeth
I'm missing more than 2 teeth
I want to get rid of my dentures
I need to have 1 or multiple teeth removed
I want to keep my dentures but make them much more stable and fit snug
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Do you have to avoid foods you love due to chewing pain or restrictions?
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No
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Do you have anxiety about your smile?
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What has kept you from getting this fixed?
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I haven't found a dentist I trust
The solutions I've found are too expensive
I haven't had time
I'm waiting until I find a solution that could last the rest of my life
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Do you feel you have an unattractive smile?
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Would you start treatment if it fits your budget?
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Is there anything else that concerns you about your smile or oral health?
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Full Name
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E-mail
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Phone Number
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